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DOI: http://dx.doi.org/10.33846/hn60301 http://heanoti.com/index.php/hn
LITERATURE REVIEW ARTICLE
URL artikel ini: http://heanoti.com/index.php/hn/article/view/hn60301
Socio-Cultural Determinants of Treatment Seeking Behavior among Tuberculosis Patients: A Systematic Review of a Qualitative Study
Imelda Sussanti Nailius1(CA), Dien Anshari2
1(CA)Department of Health Education and Behavioral Sciences, Faculty of Public Health, Universitas Indonesia,
Indonesia; [email protected] (Corresponding Author)
2Department of Health Education and Behavioral Sciences, Faculty of Public Health, Universitas Indonesia, Indonesia; [email protected]
ABSTRACT
The treatment-seeking behavior of tuberculosis patients is an important component of tuberculosis control interventions.The author undertakes a systematic review by identifying, evaluating, and interpreting the findings of similar studies to determine socio-cultural factors affecting tuberculosis patients' treatment seeking behavior.
This study employs meta-synthesis of qualitative method. The researcher search articles using keywords in the databases of Proquest, Ebsco, ScienceDirect, and Springerlink yielded results (n = 111,665). Furthermore, the screening, feasibility, and selection processes were carried out in the population of tuberculosis patients based on inclusion criteria such as complete scientific articles with qualitative research designs, including socio-cultural aspects influencing tuberculosis treatment seeking behavior which published in 2016 to 2021. As a result, there are 9 research publications which eligible for systematic review and meet the criteria. Socio-cultural factors of treatment seeking behavior of tuberculosis patients include factors of knowledge, awareness, belief, economic ability, facilities access and health facilities infrastructure, communication and family support, perceptions related to poverty, social and cultural stigma of seeking alternative medicine.Socio-cultural factors can be investigated and used as inputs in subsequent qualitative and quantitative research tailored to the characteristics and socio- cultural patterns found in Indonesia's tuberculosis patient population.
Keywords: socio-cultural factors; health seeking behavior; tuberculosis
INTRODUCTION Background
Tuberculosis is an infectious disease caused by the bacteria Mycobacterium tuberculosis, and it is one of the world's top ten causes of mortality. In 2019, the World Health Organization predicts that 10 million people were infected with tuberculosis, and 1.3 million people died from the disease.(1) Indonesia has the world's second- highest number of tuberculosis patients, with 543,874 cases reported in 2018, a tuberculosis incidence rate of 316 per 100,000 people and a tuberculosis death rate of 40 per 100,000 people, with the provinces of West Java, East Java, and Central Java reporting the most cases. Cases of tuberculosis in these three provinces accounted for nearly half of all tuberculosis cases in Indonesia (45 percent).(2)
Tuberculosis may easily spread through droplets from tuberculosis patients and can be transferred to anyone and anywhere, but it is more usually seen in adults, particularly men, who are around 1.4 times more likely than women to contract the disease, and it is found in all provinces in 2019. (2) Tuberculosis is also associated with poverty, economic stress, susceptibility, marginalization, stigma, and discrimination, making it a significant threat to human resource development and one of the Sustainable Development Goals (SDGs). (1) The case detection rate (CDR) of tuberculosis cases in 2019 was 65 percent, which is still far below the WHO-recommended target of 90 percent. This explains why the scope of tuberculosis patient discovery is still below the standard; it is anticipated that 35% of tuberculosis patients have not been found and treated, which will be a major issue and have an impact on tuberculosis transmission in the community. (2)
Efforts to control the tuberculosis program, which seeks and treats tuberculosis patients in the community, rely heavily on screening tuberculosis suspects based on their pattern of seeking treatment. Puskesmas must anticipate this by providing continuous communication, information, and education (KIE) to the community about tuberculosis information so that patients know, want, and are able to appropriately conduct tuberculosis treatment
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seeking behavior in health facilities. Inadequate treatment has led to an increase in the number of tuberculosis patients, who are a source of transmission in the community. The findings of a study on the behavior of people seeking treatment for tuberculosis in the working area of the Uitao Public Health Center in Kupang City revealed that 41.2 percent of people sought treatment at health facilities and 58.8 percent sought other treatments, 45.6 percent of people had good knowledge about tuberculosis while 54.4 percent had poor knowledge about tuberculosis,(3) Hidayat et al's (4) research at the Bandung City Health Center discovered that the factors that influence treatment seeking behavior in tuberculosis patients are community characteristics, demographic conditions, family conditions, socio-culture, knowledge, and stigma, and Purwanti et al, (5) research in Surabaya discovered that family support is a social factor that can influence tuberculosis patients in making treatment decisions. Based on the findings of the preceding studies, the pattern of patient behavior in seeking tuberculosis treatment is something that everyone involved in the discovery and control of tuberculosis should be aware of. As a result, this study is important and appropriate for collecting information systematically and identifying socio- cultural factors that can affect patients' search for tuberculosis treatment as a foundation for conducting health promotion for the success of the tuberculosis case finding and control program in Indonesia.
Purpose
By employing a qualitative approach, this systematic review focuses on identifying, evaluating, and interpreting research findings linked to socio-cultural factors that influence tuberculosis patients' treatment seeking behavior.
METHODS
In the meta-ethnographic category, this study employs a qualitative research approach with a meta- synthetic study design. A systematic review was carried out to study and synthesize the literature on socio-cultural aspects that influence tuberculosis patients' treatment delay and treatment seeking behavior. Accessible scientific journal provider sites such as ScienceDirect, ProQuest, Ebsco, and SpringerLink were used to collect sample articles. Remote-lib.ui.ac.id is used to access the site. PICOS characteristics such as "tuberculosis" or "TB" or
"TB", "socio-cultural" and "health-seeking behavior" were used as keywords to find related articles. Table 1 shows the criteria used to evaluate each publication.
Table 1. Inclusion and exclusion criteria
Inclusion Criteria Exclusion Criteria
Population
Tuberculosis patients, families of tuberculosis sufferers, health workers/shamans who treat tuberculosis sufferers
Healthy general population, people with AIDS or other diseases Research design
Qualitative: semi-structured in-depth interviews, focus group discussions, observation and Mixed Method
Quantitative: Systematic review, conference research protocol Year, language and accessibility
Article published from 2016-2021
Articles published in English and Indonesian
Peer-reviewed article
Scientific journal (scholarly journal)
Not fully available
Article cannot be accessed
Research findings
The relationship between socio-cultural factors that influence treatment-seeking behavior for tuberculosis sufferers
Findings are not related to socio-cultural factors or to tuberculosis sufferers
The critical appraisal skills program (CASP) guidelines for qualitative research are used to assess article quality.(6)The guide consists of ten questions organized into three sections that include the legitimacy of research results, research results, and research benefits. The first and second questions had three options for answers: "yes,"
"no," or "cannot be answered." The remaining questions are marked using a point system. Each question has a maximum score of 3 points and a minimum score of 1, therefore the highest overall score is 24. Articles that do not explain or defend the topic in a single question are given 1 point, articles that provide justification but do not adequately explain it in full, are given 2 points ; while the article that strongly explains and justifies the issue given, gets 3 points.
Rereading the articles used as samples until thorough notes on metaphors or concepts related to socio- cultural elements that influenced the behavior of seeking tuberculosis treatment were obtained. In addition, a matrix was created to enumerate the variables of socio-culture elements that were found as having an impact on the behavior of tuberculosis patients seeking treatment, particularly in the social and cultural components of tuberculosis sufferers. The matrix is used to help translate each variable and see how it relates to the others.
The translated variables are then combined into a single notion, which is then compared to each sample article. This stage is performed to examine if there are any common types of translation that appear in multiple samples, and then a bigger concept is formed to capture similar topics from various articles. The last part of the analysis is to design a new framework to incorporate numerous notions of socio-cultural elements that influence the behavior of seeking treatment for tuberculosis in a single uni
t.
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The findings of this synthesis are divided into two categories: social and cultural aspects. The first is social factors such as family support, the patient's view of tuberculosis, and social interactions, as well as the patient's financial or economic ability, which all influence individual treatment seeking behavior. Second, cultural factors such as habits or values, the patient's social status in society, and their knowledge of how they feel influence treatment seeking behavior and are linked to public health promotion programs.
A keyword-based literature search utilizing an electronic database yielded 111,665 items. Then the articles were filtered using inclusion criteria such as the year range (2016-2021), research articles, peer review, full text, and open access publications. 587 items were discovered to be screened after the screening. The initial screening was using the Mendeley reference system to look for duplicate journals and obtaining three duplicate articles from each search engine. The eligibility screening was then completed by determining the suitable title and abstract.
There were 21 articles that were successfully collected from the second screening. Furthermore, the publications were evaluated as a whole, taking into account the inclusion and exclusion criteria, resulting in the use of just 9 articles in the study. Figure 1 shows the flow chart for the sample article identification procedure.
Figure 1. Sample identification flowchart through database RESULTS
The research locations for the nine publications included in this study are in developing countries in Asia (India, Pakistan, Cambodia, Nepal, and Bangladesh), the Americas (Brazil, Peru), and Africa (India, Pakistan, Cambodia, Nepal, and Bangladesh) (Kenya). The number of samples in the study ranged from 19 to 203, with ages ranging from 15 to 68. Patients with tuberculosis and their families, health personnel specializing in tuberculosis control, non-governmental tuberculosis groups, and traditional healers were among the study's participants. The majority of the publications utilized semi-structured in-depth interviews and focus group discussions as data gathering methods, while four of them coupled them with a quantitative approach, using cross- sectional surveys and retrospective cohorts as data collecting methods. The characteristics of the articles used as samples can be seen in Table 3.
Table 2. Quality assessment of sample articles
First Author Clear Objective
Methods suitability
Design Sampling strategy
Data collection
Researcher and participant relationship
Ethical issues
Data analysis
Findings Implication Total score
Hussain Yes Yes 3 3 3 3 3 3 3 3 24
Adela Khan Yes Yes 3 3 3 3 3 3 3 3 24
McArthur Yes Yes 3 3 2 3 3 3 3 3 23
Kolte Yes Yes 3 3 2 3 3 3 3 3 23
Teo Yes Yes 3 3 3 3 3 3 3 3 24
Bonadonna Yes Yes 3 2 3 3 3 3 3 3 23
Shatil Yes Yes 3 3 3 3 3 3 3 3 24
Mbuthia Yes Yes 3 2 3 3 3 3 3 3 23
Marahatta Yes Yes 3 3 3 3 3 3 3 3 24
Note: Identification from Databases: SpringerLink (n = 141), ProQuest (n = 23,732), Science Direct (n = 1,110), Ebsco (n = 86,682)
Note: removed after screening: Not eligible by database automated tool (n = 111,075)
Removed due to duplicates (n = 3) Note: Screening by title and abstract (n = 587) Note: excluded because the article is in
the form of a systematic review, quantitative research, study protocol, etc. (n = 566)
Note: the article was searched for socio-cultural
factors (n = 21) Note: not taken, does not include
socio-cultural factors (n = 12) Note: the article was searched for socio-cultural
factors (n = 21) Note: excluded (n=0)
Note: articles included in the analysis (n = 9) Study identification through database
IdentificationScreeningResults
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Table 3. Characteristics of sample articles
Author (year)
Research location
Participants Age (years)
Gender Sample Design Data
collection
Main theme Hussain
et.al (2020) (14)
India TB patients, families and health workers
>15 Male and female
53 Qualitative and Quantitative with Sequential Approach
FGD and Structured Interview
The risk factors are ignorance about TB symptoms, addiction to alcoholic beverages, difficulty reaching health facilities due to long distances, and lack of communication and transportation.
Adeela Khan, et.al
(2020) (7)
Pakistan TB patients, families, health workers and authorities
15-45 Male and female
47 Quantitative approach and Qualitative approach
Cross- sectional survey and FGD
The perception that TB is related to poverty and is considered a stigma in society so that patients are afraid to reveal their disease.
Mc.Arthur et.al (2016)
(12)
India TB patients, district TB officers, doctors, TB nurses, and TB non- government organizations
18-65 Male and female
19 Quantitative approach and Qualitative approach
Quantitative data analysis and Semi- structured Interview
Younger women with tuberculosis frequently conceal their symptoms. Older women are unaware of tuberculosis because of socio-cultural hurdles and stigma. Women frequently seek therapy from private practitioners, delaying diagnosis.
Kolte. et.al (2020) (11)
Brazil TB patients and their families and community members without TB
- Male and female
53 Qualitative Semi- structured interview
The strong societal stigma associated with tuberculosis causes significant delays in treatment because people are afraid of being isolated and losing their jobs. While the majority of patients report feeling supported by their families.
Teo. et.al (2020) (9)
Kamboja TB patients 45-68 18 males and 13 females
31 Explanatory sequential study with mixed methods quantitative and qualitative approach
Retrospective cohort and in- depth interviews
People in rural areas take longer to be diagnosed with tuberculosis because they seek alternative treatment or self- medication before visiting a health facility.
This is due to a lack of perception of risk, threat, vulnerability, and stigma.
Bonadonna et.al (2017) (10)
Peru Patients with tuberculosis and their families, as well as health professionals working in the field of tuberculosis control
>18 38% are females and the rest are males
203 Qualitative with grounded theory
Semi- structured interviews and FGD
People diagnosed with tuberculosis tend to self-medicate with medicines purchased from drugstore due to societal discrimination; this is supported by the speed and low cost of treatment at drugstore.
Shatil et.al (2019) (15)
Bangladesh TB patients and family
>15 Male and female
48 Qualitative In-depth Interview
Knowledge, awareness, belief, ideology, individual, economic capacity and cultural and social awareness influence the path of seeking care for TB patients in Bangladesh.
Mbuthia et.al (2018) (8)
Kenya TB patients 27-61 32 males and 29 females
61 Qualitative exploratory with a grounded theory constructivist approach
In-depth Interview and FGD
The cause of the delay in TB diagnosis is socio-cultural factors, specifically seeking care from a pluralistic health care system that includes traditional healers, herbalists, private clinics, drugstores, and other sectors.
Marahatta.
et.al (2020) (13)
Nepal TB patients and health workers and traditional healers
23-53 Male and female
46 Qualitative phenomenologic al approach
In-depth interviews, semi- structured interviews and FGD
Long distances, poor road conditions, travel costs, and a lack of knowledge about tuberculosis and its consequences, as well as a lack of trust, prompted many respondents to seek treatment from traditional healers.
DISCUSSION Social Factors in Tuberculosis Treatment Seeking Behavior
This theme reflects the social factors that influence tuberculosis treatment behavior, as derived from several descriptive sub-themes such as the patient's view of tuberculosis, family support, community relationships, and financial or economic abilities of the community.
Individual perspectives on disease, expressed in the form of perceptions and attitudes, are one of the factors that influence treatment seeking behavior. According to research conducted by Khan et al (2020) in Pakistan, about 22% of informants thought tuberculosis was a fatal disease, 40% thought it was very serious, 35% thought
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it was not a serious disease, and some did not know about tuberculosis,(7) This is consistent with the findings of Mbutiah et al. (2017) in Kenya, who discovered that most informants did not seek early treatment after suffering tuberculosis symptoms because they assumed the symptoms were the same as a common cold that would go away on its own.(8) A lack of risk, threat, or vulnerability perception. This has an impact on people who put off obtaining treatment.(9) People diagnosed with tuberculosis do not trust health services, according to Bonadona et al., and only seek treatment in health services when they have no other option.(10)
Although family support plays a role in treatment seeking behavior, tuberculosis patients often conceal their disease status for fear of being socially excluded or discriminated against by the wider population.(7) According to Khan et al (2020)'s research in Pakistan, people seek health care for a variety of reasons. After being diagnosed with tuberculosis, approximately 45 percent will go to the nearest government health facility, 41 percent will seek counsel from private doctors, and the remaining will consult with their relatives for input and support.(7) This is in accordance with the findings of I.Kolte et al (2020) from Brazil, who discovered that family support was important for patient recovery and that most tuberculosis patients received practical and emotional support from close family members during treatment.(11)
The community also plays an important role in patients' treatment seeking behavior, as evidenced by Khan et al (2020) research, which states that tuberculosis is viewed as a serious and deadly disease that affects the emotional level and stigma of society.(7) Community stigma. Sufferers experience shame, discrimination, or stigmatization as a result of their perceived community stigma.(12)
Relationships in society and the community's financial or economic capacity also influence tuberculosis treatment seeking behavior, according to a study conducted by Maharatta et al (2020) in Nepal, which found that the cost of seeking treatment at health services is one of the factors influencing treatment seeking behavior.
Although the health service is free, the community must consider the indirect costs of travel, staying in a hotel while waiting for a sputum test, food, and other necessities for access to health,(13) As a result, knowledge of health-seeking attitudes and behavior, treatment-seeking patterns, and awareness about tuberculosis prevention must be better understood in society's diverse socio-cultural environment in order to broaden the scope of tuberculosis case discovery and management.(7)
Cultural Factors in Tuberculosis Treatment Seeking Behavior
In the exploration for tuberculosis treatment, culture includes values and habits that exist in society that are related to their social position. According to Mbutiah et al (2018)'s research in Kenya, informants seeking treatment took different treatment paths from the pluralistic health care system, which included traditional healers, herbalists, private clinics, drugstores, and the public health sector, and involves individual, socio-cultural, and structural factors.(8)
Lack of knowledge is one factor that leads people to seek alternative medicine and only visit health care facilities when they experience more severe symptoms. People with tuberculosis believe that there is no need to seek hospital treatment once symptoms appear because good alternative treatments are more readily available,(8) According to Hussein et al. research in India, public ignorance about tuberculosis symptoms, alcoholism addiction, difficulty reaching health facilities due to long distances, lack of communication, and transportation were the causes of delays in seeking treatment behavior.(14) Furthermore, a lack of knowledge about tuberculosis and its consequences, as well as trust in the community, encourages many tuberculosis patients to seek alternative medicine from traditional healers.(13)
Another study in India found that, from a cultural standpoint, younger women with tuberculosis frequently face barriers and socio-cultural stigma in their environment, causing them to conceal their symptoms, whereas older women have little awareness of the importance of tuberculosis treatment, so they frequently seek treatment from private practitioners and alternative medicine, causing the disease's diagnosis to be delayed.(12) In such a socioeconomic and cultural context, women face more stigma than men, but both male and female patients fear social exclusion as a result of tuberculosis infection.(15)
This study has several limitations, including the fact that, while the data collection process was adequate for identifying and collecting all relevant studies from January 2016 to June 2021 in digital libraries (Proquest, Ebsco, Science Direct, and Springerlink), it may have missed some relevant and potentially relevant studies. This can result in publication bias. This systematic review only considers studies that use English and Indonesian as inclusion and exclusion criteria and does not consider research published in other languages; however, by combining all relevant evidence available in English and Indonesian, we can collect 9 articles that are eligible for publication. Explain the socio-cultural factors that influence tuberculosis patients' treatment seeking behavior
.
CONCLUSION
This synthesis examines the social and cultural factors that influence tuberculosis patients' decisions to seek treatment in India, Pakistan, Brazil, Cambodia, Peru, Bangladesh, and Kenya. Family support, the patient's
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perception of tuberculosis, stigma, and patient relationships in society, as well as the patient's financial capacity, are all social factors that influence treatment seeking behavior. Cultural factors include habits in society, values, and knowledge of how they feel. The findings of this systematic review on socio-cultural determinants can be used as input for quantitative research on the Indonesian population, with determinants that can be examined from socio-cultural factors related to patient knowledge level, gender and age, income level, and qualitative research on social determinants. The stigmatization of tuberculosis patients, forms of family support, beliefs, and pluralistic health seeking behavior involving traditional healers, herbalists, drugstores, and so on are all cultural issues that need to be investigated further
REFERENCES
1. World Health Organization. Tuberculosis Report. Geneva: WHO; 2020.
2. Kemenkes RI. Profil Kesehatan Indonesia 2019. Jakarta: Kemenkes RI; 2019.
3. Bukan M, Limbu R, Ndoen EM. Gambaran Perilaku Pencarian Pengobatan Penyakit Tuberkulosis (TB) pada Masyarakat di Wilayah Kerja Puskesmas Uitao Kecamatan Semau Kabupaten Kupang. Media Kesehat Masy. 2020;2(3):8–16.
4. Hidayat D, Setiawati EP, Soeroto AY. Gambaran Perilaku Pencarian Pengobatan Pasien Tuberkulosis di Kota Bandung. J Sist Kesehat. 2017;3(2):65–72.
5. Ca YP, Fisty A, Azizah N, Chalidyanto D. The Impact of Social Factor on Decision Making in TB Patients:
An Approach to Consumer Behavior in Health Sector. Health Notions. 2018;2(11):1105–9.
6. Panchal K, Damodaran M. Computation of the Flowfield in the Vicinity of an Electric Vehicle Platform.
Lect Notes Mech Eng. 2017;(2018):333–41.
7. Khan A, Shaikh BT, Baig MA. Knowledge, Awareness, and Health-Seeking Behaviour Regarding Tuberculosis in a Rural District of Khyber Pakhtunkhwa, Pakistan. Biomed Res Int. 2020.
8. Mbuthia GW, Olungah X, Owour C, Ondicho TG. Mbuthia, Olungah GW, Ondicho GO, Gesora T. PLoS One. 2018;13(11).
9. Teo AKJ, Ork C, Eng S, Sok N, Tuot S, Hsu LY, et al. Determinants of Delayed Diagnosis and Treatment of Tuberculosis in Cambodia: A Mixed-methods Study. Infect Dis Poverty. 2020;9(1):1–12.
10. Bonadonna LV, Saunders MJ, Zegarra R, Evans C, Alegria-Flores K, Guio H. Why wait? The Social Determinants Underlying Tuberculosis Diagnostic Delay. PLoS One. 2017;12(9).
11. Kolte IV, Pereira L, Benites A, Sousa IMC de, Basta PC. The Contribution of Stigma to the Transmission and Treatment of Tuberculosis in a Hyperendemic Indigenous Population in Brazil. PLoS One. 2020;15(12).
12. McArthur E, Bali S, Khan AA. Socio-cultural and Knowledge-based Barriers to Tuberculosis Diagnosis for Women in Bhopal, India. Indian J Community Med. 2016;41(1):62–4.
13. Marahatta SB, Yadav RK, Giri D, Lama S, Rijal KR, Mishra SR, et al. Barriers in the Access, Diagnosis and Treatment Completion for Tuberculosis Patients in Central and Western Nepal: A qualitative Study among Patients, Community Members and Health Care Workers. PLoS One. 2020;15(1).
14. Hussain T, Tripathy SS, Das S, Satapathy P, Das D, Thomas B, et al. Prevalence, Risk Factors and Health Seeking Behaviour of Pulmonary Tuberculosis in Four Tribal Dominated Districts of Odisha: Comparison with Studies in Other Regions of India. PLoS One. 2020;15(4):1–17.
15. Shatil T, Khan N, Yunus FM, Chowdhury AS, Reza S, Islam S, et al. What Constitutes Health Care Seeking Pathway of TB Patients: A Qualitative Study in Rural Bangladesh. J Epidemiol Glob Health. 2019;9(4):300- 8.
